Provider Demographics
NPI:1043549637
Name:MANZANO, SHANTI KAY (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:SHANTI
Middle Name:KAY
Last Name:MANZANO
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1075
Mailing Address - Street 2:
Mailing Address - City:KOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96756-1075
Mailing Address - Country:US
Mailing Address - Phone:808-639-7255
Mailing Address - Fax:
Practice Address - Street 1:5476 KOLOA ROAD, 2F
Practice Address - Street 2:
Practice Address - City:KOLOA
Practice Address - State:HI
Practice Address - Zip Code:96756
Practice Address - Country:US
Practice Address - Phone:808-639-7255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X
CA235421041C0700X
HI38601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling